An Interview Is a Meeting Between You and the Patient

Cheryl Bayle Pages 50 - 56 The Interview Chapter 4 ( Jarvis )

 An interview is a meeting between you and the patient  The goal is to record a complete health history, which will help you begin to identify the person’s health, strengths and problems and functions as a bridge to the next step in data collection, the physical examination

Subjective data : what the person says about himself or herself

 In an interview, the patient is in charge, meaning that they know everything about their own health state and you know nothing

When you have a successful interview, you:

1. Gather complete and accurate data about the person’s health state, including the description and chronology of any symptoms of illness 2. Establish rapport and trust so the person feels accepted and thus free to share all relevant data 3. Teach the person about the health state so that the person can participate in identifying problems 4. Build rapport for a continuing therapeutic relationship; this rapport facilitates future diagnoses, planning, and treatment 5. Begin teaching for health promotion and disease prevention

 The interview is similar to forming a contract between you and your patient  The contract concerns what the person needs and expects from the healthcare system and what you, the healthcare professional, have to offer

Your Mutual Goal : optimal health and health care for the patient

Contract’s terms:

 Time and place of the interview and succeeding physical examination  Introduction of yourself and a brief explanation of your role  The purpose of the interview  How long it will take  Expectation of participation for each person  Presence of any other people ( ie. Patient’s family, other healthcare professionals, students)  Confidentiality and to what extent it may be limited  Any costs that the patient must pay Cheryl Bayle Pages 50 - 56 The Process of Communication

 Communication is more than just talking and hearing. It’s all behaviour, conscious and unconscious, verbal and nonverbal. All behaviour has meaning.

 Reflectivity is one of the central skills of relational practice.  Reflectivity involves “ a combination of self-observation, critical scrutiny, and conscious participation…and paying attention to who, how, and what you are doing in the moment” as you work with patients and families

Sending

 You are most aware of your verbal communication ( ie. Words you speak, vocalizations, the tone of your voice ) than you are with your nonverbal communication ( posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair )  Non verbal communication probably is more reflective of your true feelings.  A high degree of reflectivity is required to remain attuned to your nonverbal communication during the interview and physical examination

Receiving

 The receiver attaches meaning determined by his or her past experiences, social and family contexts, culture, and self-concept, as well as current physical and emotional states  The receiver has their own interpretation

Attending to Power Differentials

 Nurses and other healthcare professionals have more knowledge about the healthcare system and have influence over the access that patents have to health care  Healthcare professionals also have advantages such as education, language skills, and employment, which can position them as relatively powerful in relation to patients  It is important to be aware of your power and privilege relative to patients, families, and colleagues are reflected in the way you communicate, both verbally and nonverbally

Communication Skills

Unconditional Positive Regard

 Having a generally optimistic view of people: an assumption of their strengths and an acceptance of their limitations  An atmosphere of warmth and caring is necessary  The must feel that he or she is accepted unconditionally  Help them to be increasingly responsible for themselves Cheryl Bayle Pages 50 - 56 Empathy

 Viewing the world from the other person’s inner frame of reference while remaining yourself  Recognizing and accepting the other person’s feelings or actions without criticism  Understand with the person how he or she understands his or her world

Active Listening

 Requires your complete attention  Let the person talk from his or her own outline; nearly everything that is said will be relevant  Listen to the way a person tells the story, such as difficulty with language, impaired memory, the tone of the person’s voice, and even to what the person is leaving out

Attending to the Physical Setting

Ensure Privacy

 Aim for geographical privacy - a private room in the hospital, clinic, office, or home  If geographical privacy is not available, “ psychological privacy” by curtained partitions may suffice as long as the person feels sure no one can overhear the conversation or interrupt

Refuse interruptions

 Discourage other health professionals from interrupting you with their need for access to the patient  You need to concentrate and to establish rapport

Physical Environment

 Room temperature should be at a comfortable level  Provide sufficient lighting so that you can see each other clearly  Reduce noise by turning off the radio, or television  Remove distracting objects or equipment such as files, mail, clutter or your lunch  Distance between you and the patient should be one and a half meters (twice arm’s length)  Arrange equal –status seating and sit at eye level. Avoid standing. Standing communicates your haste, and it assumes superiority.  Arrange face-to-face position when interviewing the hospitalized bedridden person Cheryl Bayle Pages 50 - 56 Dress

 Patient should remain in street clothes except in the case of an emergency  Your appearance and clothing should be appropriate to the setting and should meet conventional professional standards

Note Taking

 Try to keep note taking to a minimum and try to focus on your attention on the person  Any recording you do should be secondary to the dialogue

Disadvantages of note taking:  Breaks eye contact too often  Shifts your attention away from the person, diminishing his or her sense of importance  Can interrupt the patient’s narrative flow. You may say “ Please slow down; I’m not getting it all”. The patient’s natural mode of expression is lost.  Impedes your observation of the patient’s nonverbal behavior  It is threatening to the patient during the discussion of sensitive issues (ie. Amount of alcohol and drug use, number of sexual partners, or incidence of physical abuse)

Tape and Video Recording

 The recording is an excellent teaching tool to study objectively your abilities as an interviewer  Audio recording demonstrate how you can improve your communication ( “ I need to watch my interrupting. I cut her off that time” )

 Video recording can detect richer detail in nonverbal behavior (“ It was good that I leaned toward her when she paused that time. I think it helped her continue.”)

Ethical Considerations to Video and Tape Recording:

 Obtain consent before you start  Explain to the person the purpose of the recording ( whether for teaching, supervision, research)  Exactly who will hear it ( you, your supervisor) and that it will be destroyed Cheryl Bayle Pages 50 - 56 Techniques of Communication

Introducing the Interview

If you are nervous about how to begin, remember to keep the beginning short (“Ms. Tang, I want to ask you some questions about your health so that we can identify what is keeping you health and explore any problems”)

The Working Phase

Open Ended Questions

 Open ended questions asks for narrative information and states the topic to be discussed but only in general terms (“ Tell me why you have come here today” or “What has been most challenging”)

 Open ended questions leaves the person free to answer in any way

 As the person answers, stop and listen

“Listening to” involves:

 Attending to how people describe their health concerns in the larger context of their lives  Observing their nonverbal communication  Listening to their beliefs about health and illness

“Listening for” involves:  Tuning into what is of particular concern to patients and families  Listening for the emotions people convey and for the capacities and strengths that they have  Also listen for things that patients may not be saying yet seem relevant ( ie. Where the patient answers with a short phrase, pauses, and then looks at you expecting to receive some direction of how to go on.)

Closed or Direct Questions

 Closed or direct questions ask for specific information  Either yes or no, or a forced choice  Use the direct questions after the person’s opening narrative to fill in any details he or she left out  Use direct questions when you need specific facts ( ie. Asking about health problems)  Ask only one question at a time ( avoid bombarding them with long lists ) Cheryl Bayle Pages 50 - 56

Responses: Assisting the Narrative

The Nine Types of Verbal Responses

1. Facilitation 2. Silence 3. Reflection involve your reactions to the facts or feelings the person has communicated 4. Empathy 5. Clarification 6. Confrontation 7. Interpretation where you start to express your own thoughts and feelings 8. Explanation 9. Summary

Facilitation

 Encourage the patient to say more, to continue with the story. Also called general leads  Shows the patient that you are interested and will listen further

Silence

 Communicates that the patient has time to think, to organize what he or she wishes to say without interruption from you

Advantages of silence  Lets the patient collect his or her thoughts  Gives you a chance to observe the person unobtrusively and to note nonverbal cues  Gives you time to plan your next approach

Disadvantages of silence  “Thinking silence” can be an interruption where it destroys the person’s train of thought.  It can be uncomfortable for beginning examiners, where the examiners feel responsible for keeping the dialogue going and feel at fault if it stops.

Reflection

 Echoes the patient’s words  Focuses further attention on a specific phrase and helps the person continue in his own way:

Patient: I’m here because of my water. It was cutting off. Response: It was cutting off? Patient: Yes, yesterday it took me 30 minutes to pass my water. Finally I got a tiny stream, but then it just closed off Cheryl Bayle Pages 50 - 56 Empathy

 An empathic response recognizes the feeling, accepts it, and allows the person to express it without embarrassment.  It strengthens rapport  The patient feels understood, which by itself is therapeutic, because it eases the feelings of isolation brought on by illness

Clarification

 Use this when the person’s word choice is ambiguous or confusing ( ie. Tell me what you mean by ‘tired blood’ )  Used to summarize the person’s words, simplify them to make them clearer, then ask if you are on the right track

Confrontation

 The frame of reference shifts from the patient’s perspective to yours  Responses now include your own thoughts and feelings  You have observed a certain action, feeling, or statement and you now focus the person’s attention on it  You give your honest feedback about what you see or feel ( “ You look Sad” or “ You sound angry” )

Interpretation

 It links events, makes associations, or implies cause: “ it seems that every time you feel the stomach pain, you have had some kind of stress in your life”  Ascribes feelings and helps the person understand his or her own feelings in relation to the verbal message

Explanation

 You inform the person  You share factual and objective information

Summary

 Final review of what you understand the person has said  Condenses the facts and presents a survey of how you perceive the health problem or need  Signals that termination of the interview is imminent